Breast surgeons rock

It takes a long time for medicine to embrace new ideas and change practice accordingly. Research, too, is painstakingly slow.

Surgery is slightly different, however. Surgeons can make small adaptations to standard operative techniques, adding their own refinements to existing procedures without absolute proof that their innovations are truly beneficial. They can merge procedures in the hope of improving outcomes for their patients.

When I was a medical student my mother was diagnosed with breast cancer. It was a fraught time as my little knowledge only served to make me feel utterly unable to guide her. She opted for a total mastectomy followed by immediate reconstruction, a major undertaking but one that was curative and the right decision for her. But that decision was not based on sound medical evidence, only her own preferences and the recommendations of her brilliant surgeons.

Now a unique audit into breast cancer surgery has produced the first national figures on how patients view the outcome of mastectomy and breast reconstruction surgery and has found that these innovations and adaptations made by the surgeons on the front line have paid off.

Eighty-eight per cent of women felt they had always been treated with respect and dignity while in hospital and 90 per cent rated the care they received as excellent or very good. More than 90 per cent were very satisfied with the competence of their consultant surgeon, and 85 per cent were very satisfied with the professionalism of the team.

More importantly, these data have finally confirmed that women prefer to undergo a breast reconstruction at the same time as they have their cancerous breast removed, so they never experience the trauma of seeing themselves without a breast and the fear of feeling less feminine. Eighteen months after reconstructive surgery, 85 per cent of women reported feeling confident in a social setting most or all of the time. Women who underwent mastectomy without reconstruction reported less positive results.

Women who chose breast reconstruction at the time of their mastectomy also reported higher levels of emotional and sexual wellbeing than those who underwent mastectomy alone.

When we are supposed to be practising only evidence-based medicine it is good to have confirmation that we are indeed getting some things right.

Losing the alcohol war

There seem to be many small rebel factions working against the Government. Alcohol has inspired the latest.

Six health organisations have walked away from the Coalition's new proposals to regulate alcohol designed to reduce drink-related illness and deaths. The deal is supposed to see supermarkets, pubs and drinks manufacturers all pledging to do their bit to reduce harmful drinking, for example by labelling items with the number of alcohol units.

The Royal College of Physicians, the British Liver Trust, the British Association for the Study of the Liver, the Institute of Alcohol Studies, the British Medical Association and Alcohol Concern have all rejected the deal. In my book, those are bodies that ought to be listened to.

One of their main concerns - to me, entirely justified - is that in formulating these plans the Government has allowed the drinks industry to drive the pace and direction of the policy.

It does look like a massive PR exercise on the part of the drinks manufacturers. They can now heavily publicise their apparent concern by making a noise about any minor changes they decide to make to alcohol levels or labelling of their products and so come out with increased sales to a hoodwinked public. It won't make

the slightest difference to our health, however.

The cost to British society occasioned by alcohol is estimated at £25 billion each year. That includes both health and crime and disorder costs. When I investigated this myself for a television programme it was clear that most drinkers have no idea how many units they consume at each sitting, or even how poisonous alcohol can be at high levels. It follows that clearly labelling cans and bottles with easy-to-read information about the number of units within them, safe drinking levels and a warning message about not exceeding these levels is a must, but it is not a solution.

The World Health Organisation has stated that action on alcohol must fall into three areas: affordability, availability and promotion. I'm not sure it is that simple. Look at countries that have strict alcohol laws and expensive drinks and it can be seen that the populations binge-drink more than in the UK and have high levels of alcoholism. The only difference is that levels of alcohol-related crime and violence are lower, almost certainly because the drinking is covert.

While I know it sounds pessimistic, I rather think we irreparably screwed up when we first legalised and promoted alcohol. It is a crippling example of exactly how hypocritical and ill thought-out our stimulants laws are. Just look at our drink-driving laws where the public has basically been told that a bit is OK, a lot is not, and left to try to figure it out for themselves. They don't, and people die. Sadly I fear that now it is too late, that we can never back-pedal fast enough to reverse the damage and that there is now no satisfactory solution to this problem.

Patients struck off in NHS budget reforms

The Government's reforms to the NHS are the biggest and boldest the organisation has seen since it was formed 60 years ago.

For the first time, and amid considerable controversy, the vast majority of the NHS budget will be put into the hands of family doctors.

Health unions and royal colleges have already said that they have "extreme concerns" about greater commercialisation of the NHS but I am enthused. Surely if anyone is going to know where money is most needed and best spent it is the GPs on the front line?

But some of the other proposed changes have been nothing short of ludicrous. I have written already about my mistrust of the proposal that GPs offer email consultations, and now another money-saving suggestion has been made by someone who is clearly totally out of touch with reality.

Thousands of patients face being removed from GP practice registers if they have not seen their doctor for six months. NHS managers claim that this is to ensure lists are accurate and up to date but GPs are obviously concerned that many patients will be struck off without reason and then forced to re-register when they actually need to see a doctor. The scheme is to be tested in London initially but could be rolled out elsewhere if judged a success, something I hope is unlikely.

Everybody needs to be registered with a GP, even if always seemingly fit and healthy. The age group that will suffer most from this scheme are the twenty- to thirtysomethings who are rarely ill purely because of their age. This scheme may simply panic patients into popping along twice a year to take up an appointment slot for no reason other than to ensure they remain on the books.

I don't subscribe to the argument that everyone should be going in for an annual check-up anyway - this usually throws up more issues than it solves and will take considerable time and money.

Over and above this it is men, already notoriously bad at going to doctors in the first place, who will be most likely to be removed from lists.

Women have far more reasons to see GPs because of contraception, smear tests, breast exams and pregnancies. Men have none of these issues and therefore will rarely go to GPs before the age of about 50 when the prostate starts playing up. If the current proposals go ahead I would estimate that 75 per cent of men in the UK will be without a GP after a couple of years.

Counter-arguments include the theory that GPs keep "ghost patients" on their books in order to boost their annual income; doctors receive an annual payment of up to £100 for each person registered, regardless of whether they have had any treatment. Of course, I can see that there is a need to crack down on this and tidy lists up, but having a criterion of removing those who simply haven't been for six months shows a misunderstanding about how health services are accessed by the younger generations and will only serve to further alienate a cohort of patients whom we are only just managing to win over.

GPs can't spot every disease

Monday marked the fourth International Rare Disease Day, which saw patient organisations from more than 40 countries converging around the slogan "Rare but Equal" to stress the need for closer collaboration between patients and researchers and to shed light on the challenges rare disease presents to both patients and health professionals.

This clearly inspired the more depressing reports that quickly followed about how our GPs are missing one in four cancer cases, sending patients away having dismissed early warning signs as minor ailments.

It has long been reported that Britain has one of the lowest cancer survival rates in Europe.

Experts blame late diagnosis for the alarmingly high death rates.

More than half of those with the rarer cancers, which account for around half of all cases, have to see their GP repeatedly before they are finally referred to a specialist.

Rare cancers include kidney, thyroid and gall bladder cancers, and those of the blood and lymphatic system such as myeloma, leukaemia and lymphoma. They are difficult to diagnose as the symptoms are often vague or similar to many other more common conditions.

The reasons for this apparent failure are certainly multifactorial but include the simple fact that if you don't see a condition very often then you are highly likely not to think of it as a possibility. Coupled with a reluctance and dislike among doctors to have to diagnose something grim and break the news to a patient, and you can see why these results may be occurring.

These reports did initially cause me to briefly question the wisdom of what I have long considered to be the single most useful rule of thumb any doctor needs to know. First described by the 14th-century logician and Franciscan friar, William of Ockham, and known as "Occam's razor" it suggests that "entities should not be multiplied unnecessarily". A more useful interpretation for scientists is "when you have two competing theories that make exactly the same predictions, the simpler one is the better".

It means a common condition is probably more likely to be responsible for a patient's symptoms than a very rare one. This remains true for most cases that GPs see and will probably be the guidelines under which most practise, even if subconsciously.

By sticking to this adage doctors will be correct for most of their diagnoses, and only the few incidences of rarer disease may be missed.

Rare cancers can be hard to pick up, and the recent reports of patients who made multiple trips to GPs and to A&E and still failed to get diagnosed suggest that it isn't always the doctors who are at fault but the subtleties of diseases that we are still a long way from fully understanding.

Regular GP refresher courses about the more infrequently seen conditions have been suggested as a possible solution but I certainly wouldn't like to be the one who has to sell this idea to our already overstretched doctors.